Optical coherence tomography-guided percutaneous coronary intervention in multivessel coronary disease with complex lesions

Background Optical coherence tomography (OCT)-guided percutaneous coronary intervention (PCI) improves clinical outcomes through enhanced stent optimisation; however, whether these benefits extend to patients with multivessel disease (MVD), characterised by greater anatomical complexity and high ischaemic burden, remains unclear. Therefore, this study aimed to evaluate whether OCT guidance improves clinical outcomes in patients with MVD undergoing PCI. Methods We conducted a post hoc subgroup analysis of the OCCUPI trial, focusing on patients with MVD (diameter stenosis ≥50% in ≥2 major epicardial coronary arteries) with at least one complex lesion. The primary outcome was major adverse cardiac event (MACE), a composite of cardiac death, myocardial infarction, stent thrombosis or ischaemia-driven target-vessel revascularisation over 1 year. Results Among the as-treated population in the OCCUPI trial (n=1604), 985 (61.4%) patients had MVD and 575 had single-vessel disease. In patients with MVD, OCT-guided PCI (n=515) was associated with a lower risk of 1-year MACE than angiography-guided PCI (n=470) (4.7% vs 8.9%; HR 0.51, 95% CI 0.31 to 0.85; p=0.008), with consistent treatment effects observed across disease extent (p for interaction=0.202). Among the OCT-guided patients, 355 (70.2%) achieved the prespecified OCCUPI optimisation criteria, whereas 151 (29.8%) did not. Stent optimisation was associated with significantly lower MACE rates (3.1% vs 8.6%; p=0.011) and consistent benefits were observed across MVD and single-vessel disease (p for interaction=0.521). Conclusions In patients with MVD and complex lesions, OCT-guided PCI was associated with a lower risk of 1-year MACE than angiography-guided PCI particularly when stent optimisation on OCT was achieved.